Different ways of seeing opioids makes epidemic difficult to solve

Two of the most recognized problems in the opioid epidemic — overprescription and doctor-shopping — couldn’t be more different.

Overprescription — when patients receive more medication or stronger doses than they need — is generally acknowledged as a widespread issue. Doctor-shoppers, on the other hand, are a smaller group people actively seeking fraudulent prescriptions.

The problem is that it’s tricky, if not impossible, to measure the two.

Some guidelines exist about how patients should be treated, but part of the problem with overprescription is that excessive medication ends up being sold. However, nobody knows how much of every prescription ends up in the wrong hands.

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“The figure you are looking for is an impossible anomaly to determine,” Lisa McElhaney, the president of the National Association of Drug Diversion Investigators, wrote to the BND in an email. “Any response to that question would simply be an individual’s ‘guess-timation’ based upon their varied knowledge in their respective field of study.”

The federal Drug Enforcement Agency doesn’t know, either.

“DEA does not maintain a system that would provide an estimate of what percentage of opioid prescriptions are diverted,” James Jones, a Public Information Officer with the DEA, wrote in an email.

State agencies also don’t know, including the Illinois State Police, which leads drug task forces; the Illinois Department of Human Services, which emphasizes drug treatment; and the Illinois Department of Public Health, which focuses on drug prevention.

Some have estimated that diversion levels reach up to 50 percent, but no one knows for sure.

“Those numbers do not surprise me,” Dr. Nirav Shah, director of the state Department of Public Health, said in an interview.

Potential doctor-shoppers

Illinois has a much better grasp of the number of potential doctor-shoppers there are in the state, but changing definitions of who they are have make it difficult to understand how large the problem is.

According to Illinois law, medication-shopping is when a patient who already has a prescription gets or fills another one without telling the doctor or pharmacist about the first one.

Illinois once defined a potential doctor-shopper as someone who visited six or more prescribers, or six or more pharmacies — or both — in a one-month period. But in 2015, the Heroin Crisis Act, which overhauled drug laws, cut those numbers in half.

Still, the difference between the “either-or” and “or-both” categories is a big one, and it lies at the heart of how the problem is viewed.

Currently, DHS uses the “or-both” category, meaning that someone has to visit three prescribers and three pharmacies in one month to be considered a potential doctor-shopper.

The “or-both” threshold is more difficult to meet than the “either-or” threshold. So the problem looks smaller at the outset, and when the numbers decline, the problem appears to be almost solved.

The number of “or-both” doctor-shoppers appeared to fall steeply over the years using the old standard. In 2008, there were 1,700 of them, but in 2016, there were only around 270. The numbers for 2016 have not been finalized yet.

But, if DHS used the “either-or” approach, the number of doctor-shoppers would have appeared much larger from 2008 through 2016. Using the old standard, those numbers range from 3,800 to 2,700 patients, averaging slightly more than 3,000 a year during the nine-year period.

When the Heroin Crisis Act lowered the threshold to three prescribers or three pharmacists in a one-month period, or both, it dramatically reframed the visibility of potential doctor-shoppers.

At first glance, the new standard shows two eye-popping trends: First, instead of steadily declining, potential doctor-shoppers have remained constant over time. Second, there were 70 times more of them from 2008 through 2016.

With the new threshold, there were about 56,000 “or-both” patients a year from 2008 through 2015, falling to around 47,500 in 2016, according to data from DHS. The numbers for 2016 have not been finalized yet.

However, if DHS had measured doctor-shoppers with the “either-or” approach, the number of potential doctor-shoppers under the new standard would have skyrocketed, ranging from 226,000 to 360,000 and averaging 281,000 a year from 2008 through 2016.

It’s unclear why the law allows two different ways of interpreting potential doctor-shoppers, but the state Department of Human Services stated that it looks at the issue using “or-both” in order to minimize false-positives.

When a patient reaches the doctor-shopping threshold, DHS reviews that person’s record to see whether it is a false positive, Meredith Krantz, a spokeswoman for DHS, wrote in an email. If there are too many false positives, then “alert fatigue” could set in among medical professionals.

“(We use) a set of algorithms that help reduce false positives and ensure the unsolicited reports meet grant requirements before they are reviewed further,” DHS wrote.

But, the department said, there is no way to go back through the years to see how many unsolicited reports were sent, and the number of false positives is not tracked.